Mngement of n extensive prtil nd full thickness skin urn in dog with the id of medicl honey Mrvelis G. DVM > Astrct A 9-yer-old mle mixed reed dog ws dmitted for the mngement of prtil nd full thickness therml urn tht ws covering 45% of his ody including the dorsl, lterl nd ventrl thorx nd domen, medil thigh nd cudl elow. Medicl honey (L-Mesitrn soft) ws pplied to the urn re on dily sis nd dressed with sorent pds resulting in complete heling y contrction nd epithelilistion 35 dys fter initil dmission. Medicl honey my e used s n effective lterntive for the tretment of extensive skin urns. Voutsinou A. DVM, MSc Tsmp N. DVM > Introduction Therml urn injuries re rrely encountered in smll niml prctice. Tissue exposure to extreme tempertures usully results in cellulr destruction ensuing in locl or systemic effects. 1 Therml urns my e the result of ccidentl or delierte exposure to flmes or fire, sclds from hot liquids or gses, or from contct with hot surfce. 2 Clssifiction of urning injuries depends on the skin surfce re tht is ffected nd lso on the depth of tissue destruction (superficil, prtil thickness or full thickness urns). 1,2 Burn depth serves s criticl prognostic indictor; superficil or prtil thickness urns my hel without surgicl intervention, ut full thickness urns require either surgicl reconstruction or secondry heling y contrction nd epitheliliztion depending on the extent of the surfce re involved. 2 Honey hs een used for the tretment of humn wounds since ncient times with fvourle outcomes. The heling properties of honey re due to its nticteril ction due to the hydrogen peroxide production tht ensues fter contct of honey with wound exudte, flvonoids nd high sugr content tht result in hyperosmosis eventully leding to cteril dehydrtion, deth nd hypercidity. 3,4 Other properties of honey include nti-inflmmtory nd deodorising effects, deriding ction nd ccelertion of tissue growth nd grnultion tissue formtion. 3-6 Nturl honey my contin Bcillus spp nd Clostridium spp nd must not e used for medicl purposes. Sterile, rdited honey tht is derived from specific pthogen-free hives is recommended for medicl use. 6,7 Mnuk honey nd Medihoney re the types of honey most commonly used in clinicl prctice in humns. More recently, nother medicl product consisting of 40% irrdited honey, known s L-Mesitrn, ws introduced to humn medicine. 8-10 Medicl honey hs lso een recently introduced to veterinry medicine. 5,6,11-14 There is, however, pucity of scientific documenttion concerning the wound heling effects of medicl honey in veterinry medicine nd only few studies conducted in equines hve shown promising results. 13,14 The purpose of the present study ws to evlute the therpeutic effect of medicl honey in second intention heling of n extensive Corresponding uthor: Compnion Animl Clinic, Fculty of Veterinry Medicine, Aristotle University of Thessloniki Voutyr 11, 54627 Thessloniki e-mil: mkdvm@vet.uth.gr Key words urn, honey, dog, wound heling Ppzoglou L.G. * Professor of Surgery, DVM, PhD, MRCVS Hellenic Journl of Compnion Animl Medicine Volume 4 Issue 2 2015 35
Figure 1. Extensive therml skin urn on the lterl dorsl nd ventrl thorx of 9-yer-old dog 24 hours fter referrl nd following lvge nd deridement. Helthy grnultion tissue is evident in the urn re. prtil nd full-thickness skin urn in dog nd possily to suggest n lterntive therpy to the clssic ointments nd/or wound dressings. > Cse report A 9-yer-old mle mixed reed dog ws referred ecuse of n extensive truncl therml skin urn. The referring veterinrin, fter performing n ggressive deridement of the necrotic tissue, hd clened the wounded re thoroughly for the pst six dys, once dily, with chlorhexidine solution nd pplied silver sulfthizine crem topiclly. Additionlly, the dog ws treted with intrvenous fluids nd electrolytes, ntiiotics nd nlgesics. On the dy of dmission, the dog ws dignosed with prtil nd full thickness urns ffecting 45% of his ody s estimted y clcultion of the totl ody surfce re. 1 A few necrotic res were evident on the dorsl thorx nd grnultion tissue extended to the dorsl, lterl nd ventrl thorx nd domen, medil thigh nd cudl elow. Under generl isoflurne nesthesi, the wounded re ws further derided to remove the necrotic skin over the thorx, lvged with norml sline, nd dressed with Figure 2. The urn ws lvged with wrm norml sline solution 24 hours fter referrl nd efore the ppliction of medicl honey. 36 Ιατρική Ζώων Συντροφιάς Τόμος 4 Τεύχος 2 2015
Figure 3. Medicl honey L-mesitrn ws pplied to the urn. non-dherent pds (Figures 1 nd 2). After 24 hours, nd following lvge with norml sline, L- Mesitrn soft (Triticum, Netherlnds) ws pplied topiclly with sterile gloved hnd once dily nd the wound ws dressed with sorent dressings (Zetuvit E, Hrtmn Germny) nd ndges (Figure 3). Helthy grnultion tissue ppered within 72 hours. L- Mesitrn ws pplied dily following lvge of the urn re. For the first three dys, ndge chnges were performed under propofol nesthesi. Therefter, since L-Mesitrn ppliction ws ccompnied y discomfort, trmdol ws dministered for pin relief t dose of 3 mg/ kg im TID (Trml, Vinex Greece) long with crprofen (Rymdil, Zoetis Greece) t dose of 2 mg/ kg id per os. Epitheliliztion of the wound ws evident five dys fter initil dmission (Figures 4 nd ). Ten dys fter dmission, contrction Figure 4 &. Five dys fter dmission. The urn wound shows significnt contrction nd epitheliliztion. Hellenic Journl of Compnion Animl Medicine Volume 4 Issue 2 2015 37
Figure 5 &. Ten dys fter dmission. The urn wound shows significnt reduction in size. of the wound ws significnt (Figures 5 nd ). On dy 15, the epithelium hd covered 50% of the urn re nd on dy 20, 75% of the urn heled (Figures 6 nd ). On dy 26, the dog ws dischrged s 90% of the urn hd heled, nd contrction nd epitheliliztion were sufficient (Figures 7 nd ). Smll res round the crnil thighs were still not heled nd the owner ws dvised to pply mupirocin clcium ointment (Bctron ointment, GlxoSmithKline, Greece) topiclly, twice dily, until heling ws complete. On re-exmintion 35 dys fter initil dmission, the urn hd heled completely (Figure 8). One yer lter, the dog is doing well. > Discussion In the cse reported herein, the extensive urn ws ddressed initilly t the time of dmission with surgicl deridement of residul devitlized tissue to void secondry infection nd sepsis. 1 This pproch llowed for shift from the inflmmtory to the prolifertive phse of wound heling, creting helthy grnultion tissue ed. 1,2 In this cse, due to the extensive re of the urn wound nd the difficulty to pursue surgicl reconstruction using flps or grfts, we opted for conservtive pproch using locl ppliction of medicl honey tht hs shown promising therpeutic results for the heling of wounds nd urns in humns, equines nd dogs. 3,5,11,13,14,15 L-Mesitrn Figure 6 &. Twenty dys fter dmission. Most of the urn wound ws covered y new epithelium. 38 Ιατρική Ζώων Συντροφιάς Τόμος 4 Τεύχος 2 2015
Figure 7 &. Twenty-six dys fter dmission, ninety percent of the urn wound heled. soft ppered to e good lterntive for the mngement of urn wounds in vivo nd in vitro in humns. 8,10 Mnuk honey hs een lso found to minimize the wound re y decresing retrction nd overll to reduce heling time compred to controls, when pplied on experimentl equine wounds locted on the lims. 13,14 L-Mesitrn soft ws reported to ccelerte heling time nd provide more re-epitheliliztion when compred to povidone iodine ointment nd silver sulphdizine crem tht were pplied to humn urns nd in vitro urn wounds, respectively. 8,10,16 The outcome of this dog supports the findings in equines, nd we found tht L-Mesitrn soft seems to help in speeding up the heling process y incresing grnultion tissue formtion time nd reducing wound contrction nd epitheliliztion time. As result, the wound heled lmost entirely within 26 dys. Prtil-thickness urns usully hel within 2-3 weeks wheres full- thickness urns tke longer to hel. 2 In the present cse, the urn ws prtil nd full-thickness nd heled lmost completely within the pprently short period of 26 dys with no complictions in terms of wound contrcture involving the lims. 2 Appliction of L-Mesitrn soft directly to the skin is followed y immedite coverge with sorent ndges to void run-off from the urn surfce. 12 In this study, when L-Mesitrn soft ws pplied to the urn, the dog seemed to e in discomfort due to pin. Pin ws controlled y dministering opioids nd non-steroidl nti-inflmmtory drugs. Figure 8. Thirty-nine dys fter dmission, the wound heled completely. Hellenic Journl of Compnion Animl Medicine Volume 4 Issue 2 2015 39
The exct cuse of honey-relted pin remins uncler nd my e ssocited with hyperlgesi due to the urn injury nd not to the honey itself or to the irrittion of the tissues during removl of the honey-soked dressings. 3,5,17 In the present cse, systemic ntimicroils were given empiriclly y the referring veterinrin on presenttion. However, systemic ntimicroil therpy in the urn ptient should only e dministered in the presence of sepsis. On referrl to the uthors clinic, no systemic ntiiotics were given throughout the whole tretment period since no signs of sepsis were present nd so s to prevent the development of resistnt microorgnisms. In ddition, in the presence of grnultion tissue ny ntiiotics should e discontinued. Mupirocin ointment should not e used or used springly in dogs nd only following culture nd sensitivity testing s resistnce to methicilin-resistnt Stphylococcus is incresingly reported in oth humns nd nimls. 18 One yer fter dmission, the dog showed no restriction of movement or ny other complictions relted to heling. In conclusion, L-mesitrn soft my provide n lterntive to more expensive topicl or systemic wound medictions for the mngement of extensive urns. L-Mesitrn soft seems to id in speeding up grnultion tissue formtion nd reducing second intention heling time in dogs with extensive therml skin urns. > References 1. Bohling MW. Burns. In: Veterinry Surgery Smll Animl. Tois KM, Johnston SA (eds). Elsevier: St Louis, 2014, pp. 1291-1302. 2. Pvletic M, Trout NJ. Bullet, ite, nd urn wounds in dogs nd cts. Vet Clin Smll Anim Prct 2006, 36: 871-893. 3. Vndmme L, Heynemn A, Hoeksem H, Verelen J, Monstrey S. Honey in modern wound cre: systemtic pproch. Burns 2013, 39: 1514-1525. 4. Moln PC. The role of honey in the mngement of wounds. J Wound Cre 1999, 8: 415-418. 5. Mthews KA, Binnington AG. Wound Mngement using honey. Comp Contin Educ Prct Vet 2002, 24: 53-60. 6. Overguw PAM, Kirpensteijn J. Appliction of honey in the tretment of skin wounds. Eur J Com Anim Prct 2006, 16: 1-3. 7. Postmes T, vn den Bogrd AE. Honey for wounds, ulcers, nd skin grft preservtion. Lncet 1993, 342: 756-757. 8. Vndeputte J, vn Weyenerge PH. Clinicl evlution of L- Mesitrn- honey- sed wound ointment. Prof Nurs Tody 2007, 11: 26-31. 9. Morris C. The use of honey in wound cre nd the mesitrn product rnge. Wounds 2008, 4: 84-87. 10. Boekem BKHL, Pool L, Ulrich MMW. The effect of honey sed gel nd sulphdizine on cteril infections of in vitro urn wounds. Burns 2013, 39: 754-759. 11. De Rooster H, Declercq J. Honey for wound cre: myth or science? Prt 2: clinicl cses with dogs. Flemish Vet Mg, 2008, 78: 75-80. 12. De Rooster H, Declercq J, vn den Bogert M. Honey for wound cre: myth or science? Prt 1: literture overview. Flemish Vet Mg, 2008, 78: 68-74. 13. Bischoferger AS, Drt CM, Prkins NR, Drt AJ. A preliminry study on the effect of mnuk honey on secondintention heling of contminted wounds on the distl spect of the forelims of horses. Vet Surg 2011, 40: 898-902. 14. Bischoferger AS, Drt CM, Prkins NR, Kelly A, Jeffcot L, Drt AJ. The effect of short- nd long- term tretment with mnuk honey on second intention heling of contminted nd noncontmonted wounds on the distl spect of the forelims in horses. Vet Surg 2013, 42: 154-160. 15. Potokr T. Anticteril effect of medicl honey L-Mesistrn nd its effect on wound heling. L- Mesitrn Clinicl dt file 2014: 1-5. 16. Mlik KI, Mlik MA, Aslm A. Honey compred with silver sulphdizine in the tretment of superficil prtil-thickness urns. Int Wound J 2010, 17: 413-417. 17. Dvidson JR. Current concepts in wound mngement nd wound heling products. Vet Clin Smll Anim 2015, 45: 537-564. 18. Loeffler A, Linek M, Moodley A, Gurdssi L, Sung JM, Winkler M, Weiss R, Lloyd DH. First report of multiresistnt, meca positive Stphylococcus intermedius in Europe: 12 cses from veterinry dermtology referrl clinic in Germny. Vet Derm 2007, 18: 412-421. 40 Ιατρική Ζώων Συντροφιάς Τόμος 4 Τεύχος 2 2015